Telemedicine Consent Form

1. I authorize Beverly D. Kindblade, MS, RDN, CD, Seattle Nutrition and Beve Kindblade Consulting to allow me/the patient to participate in a telemedicine (videoconferencing and phone) service.
2. The type of service to be provided by via telemedicine is under the specialty of Nutrition Counseling and Medical Nutrition Therapy.
3. I understand that this service is not the same as a direct patient/healthcare provider visit because I/the patient will not be in the same room as the healthcare provider performing the service.
4. Beverly D. Kindblade, MS, RDN, CD has fully explained to me the nature and purpose of the videoconferencing technology and has also informed me that our sessions will be HIPAA-compliant to protect my healthcare privacy.
5. I understand this technology may include interruptions and/or technical difficulties depending on the connection between my internet service provider (ISP) and the company providing the internet service by my healthcare provider. I am aware that either my/the patient’s healthcare provider or I can discontinue the telemedicine service if we believe that the videoconferencing connections are not adequate for the situation.
6. I understand that the telemedicine session will not be audio or video recorded at any time.
7. I agree to permit my/the patient’s healthcare information to be shared with other individuals for the purpose of scheduling appointments and billing claims to my healthcare insurance company.
8. I acknowledge that I have the right to request the following:
   • Omission of specific details of my/the patient’s medical history/physical examination that are personally sensitive, or 
   • Termination of the service at any time.
9. It is the responsibility of the telemedicine provider, Beverly D. Kindblade, MS, RDN, CD, to conclude the service and terminate the videoconference connection.
10. I/the patient understand(s) that my/the patient’s insurance will be billed by Beverly D. Kindblade, MS, RDN, CD as the telemedicine healthcare provider for telemedicine services. I/the patient understand(s) that if my insurance does not cover telemedicine services I/the patient will be billed directly by Beverly D. Kindblade, MS, RDN, CD for the provision of telemedicine services.
11. My/the patient’s consent to participate in this telemedicine service shall remain in effect for the duration of the specific service identified above, or until I revoke my consent in writing.
12. I/the patient agree that there have been no guarantees or assurances made about the results of this healthcare service.
13. I confirm that I have read and fully understand this Telemedicine Consent Form. All blank spaces have been completed prior to signing. I have crossed out any words or paragraphs in this form which do not pertain to me.

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